Treatment settings

A-clinics are public sector outpatient clinics in Finland that provide treatment for alcohol, drug, and other dependencies, offering help for the social, physical, and mental health difficulties connected with these. They provide a flexible range of treatments depending on the situation and case; individual, group, couple, and family therapy is available. Treatments comprise counseling, crisis care, and conversational therapy, often using various forms of brief therapy and solution-oriented methods or, in case of extended treatment, a systemic treatment model. Medical care and outpatient withdrawal treatment are also provided. At the time the study was conducted, A-clinics usually referred illicit drug abusers to a specialized care system.

The sites for the study were chosen from A-clinics in Helsinki. The four A-clinics with the largest staff participated. Each of the clinics was responsible for treating its own district. The staff of one of the clinics was trained to provide the experimental treatment, while the personnel of the other three clinics treated control patients, using their customary treatment strategies. Staff of the clinics consisted of social psychologists, social workers, and nurses.

4.4. Treatments

Experimental treatment. The entire staff of the experimental clinic was trained to provide the experimental treatment. One of the therapists had been working at the clinic for two years and the others from 3 to 4.5 years before the study commenced. All of the therapists were women.

Training consisted of lectures and, as a group, studying the manual and related materials (e.g.

video) and completing the tasks. The training was carried out during staff meetings in the year

The experimental treatment involved scheduled BZ taper with approximately 1/10 dose reductions weekly after a two-week stabilization period (Ashton, 1994). The duration of the taper thus depended on the pre-taper dose. A slower rate of taper was permitted if the subjects were unable to tolerate the reductions. A clinician monitored the taper. Treatment sessions were given individually once a week, but they were occasionally adjourned for up to three weeks if the subject had other engagements.

Table 4. The experimental program

Session 1. Introduction:

-Information on BZ withdrawal treatment

-Plan of dose reductions (depending on the subject's initial BZ dose)

-Subjects are asked to continue BZ use in their normal pattern and dosage to obtain accurate data on patterns of use

-Homework: BZ and alcohol diary

Session 2. Monitoring of BZ and alcohol use:

-Review of homework

-Monitoring of BZ use continues for 2 weeks -Homework: BZ and alcohol diary

Session 3. The advantages and disadvantages of using BZs:

-Review of homework

-Advantages and disadvantages of using BZs are discussed to detect personal problems caused by BZ dependence

-Stabilization of daily BZ doses, based on the BZ diary

-Homework: BZ and alcohol diaries, monitoring of urges to take BZs Session 4. Personal reasons served by using BZs:

-Review of homework

-Identification of functions served by BZs in order to develop alternatives -Beginning of BZ dose decreases

-Beginning of carrying out other components of the study treatment -Homework: BZ and alcohol diaries, optional homework

Session 5 and following sessions. Coping and skills:

-Review of homework

-BZ dose decreases according to plan

-Subjects are taught to recognize dysfunctional thoughts and attitudes and encouraged to develop alternative coping skills

-Educational components of the treatment and teaching a relaxation technique are carried out -Homework: BZ and alcohol diaries, optional homework

After BZ cessation:

-Sessions once a week for 1 month, then once a month for 5 months -Focus on counseling and relapse prevention

The experimental program is presented in Table 4. All of the experimental group subjects were expected to participate in the following treatment components: taper plan, BZ diaries, drinking diaries, education on BZ withdrawal by printed material and video film, assessment of BZ functions as a basis for planning alternative ways of coping, and progressive relaxation exercises. In addition, depending on subjects' individual problems, they were given advice on how to deal with high-risk situations, solve problems in general and in couple relationships, handle sleeping problems, and cope with anxiety and depression. This information and related homework assignments were included in a manual that the therapists were instructed to utilize in tailoring the techniques to meet the needs of individual subjects (Table 5). Content of the manual was adapted from Ellis (1977), Higgitt et al. (1987), Sanchez-Craig et al. (1987),

Hammersley and Hamlin (1990), Mason and Norris (1990), and Golombok and Higgitt (1993).

Table 5. Contents of the treatment manual.

1. Information and guidelines for the therapist:

-Guidelines for motivational interview

-Information on BZs (use and abuse, concomitant alcohol use, pharmacology, effects, adverse effects, withdrawal symptoms)

-Insomnia and its treatment (sleep hygiene, relaxation techniques, stimulus control, regular times for going to bed and getting up, changing the appraisals of sleep and background problems)

-Anxiety and its treatment (education, physical exercise, relaxation techniques, restructuring dysfunctional thoughts, emotions and attitudes, exposure)

-Panic and its treatment (education, restructuring dysfunctional thoughts, methods of decreasing arousal:

relaxation, shifting attention to an external focus) -Exposure treatment for avoidance

-Depression and its psychological treatment (restructuring dysfunctional thoughts) -Relaxation

2. Forms and questionnaires:

Mandatory:

-Taper plan -BZ diary -Alcohol diary

-Assessment of BZ functions Optional:

-Monitoring of drinking urges -Analysis of relapse situations -Dealing with relationship problems

-ABC diagram for analyzing dysfunctional thoughts related to behavioral and emotional problems -Problem solving

-Planning for change

-Coping with high-risk situations -Daily plan

-Weekly plan -Sleep diary

3. Material for patients:

Mandatory:

-Contents of the treatment -BZ dependence and its treatment -BZ dependence (video) Optional printed material:

-Self-confidence

-Coping with high-risk situations -Coping with stress

-Dysfunctional thoughts -Coping with anxiety -Understanding panic

Control treatment. Treatment of control group subjects involved a gradual BZ taper scheduled and managed by a clinician, and discussions with a nurse or therapist. The researchers did not define the rate of the taper or themes of the discussions beforehand.

Diaries of BZ doses were used as a basis for dose reductions, but no other agreed-upon techniques were used. Treatments in the three A-clinics differed from each other to some extent. The individual nurses and therapists applied their customary approaches.

At A-clinic 1, the therapists used mainly supportive approaches. Over the course of the study, staff turnover occurred, and the clinic altered its practices; some cognitive approaches were adopted (one of the therapists did cognitive rehearsals and the clinic begun to use educational material similar to that in the experimental clinic), and supportive group treatment was offered to five subjects (total number of subjects 20). Thus, the treatments of the

experimental and control groups at this clinic became more similar as they dealt with some common themes. However, treatment was not structured but depended on the approaches of individual therapists.

In A-clinic 2, the treatment orientation was supportive. A doctor planned and monitored a graded BZ reduction, which was carried out by a nurse. In addition, supportive discussions with a therapist were offered. The clinic treated six subjects.

In A-clinic 3, the treatment commenced in a session, in which a doctor, nurse, and therapist together interviewed the patient and planned the treatment. In subsequent sessions, the patients usually met a doctor and a therapist. Some of the subjects also met a nurse, who dealt with daily BZ doses. The approach the therapists used was brief psychotherapy with strength perspective and focused problem-solving techniques. A total of 11 subjects received treatment at this clinic.

4.5. Randomization

Subjects were randomized into two treatment groups by the sealed envelope method. All experimental treatment was offered at one of the clinics, and the individuals who were assigned to the control group received treatment-as-usual at the clinic nearest to their place of residence. Prior to allocation to treatment, other psychotropics were washed out, and BZ use was allowed to stabilize. If the subject met DSM-III-R criteria for major depression,

fluoxetine medication was used. Zopiclone was included in the study preparations as a widely used BZ receptor agonist.